1. Stainless Steel Crowns for treating primary molars in a General Practice setting – An Audit G.D Taylor, K Perry & R.R Welbury
Greig D Taylor
BSPD Annual Meeting London
Wednesday 17th September 2014

2. Introduction
Historically, conventional Glass Ionomer cement has been the material of choice for restoring carious deciduous primary molars in the General Dental Practice setting where I carried out my vocational training.
My practice was based in SIMD Category 1 area (most deprived on the scale) and is identified as an area where individuals may experience multiple deprivation and are at greater need for support and intervention.
Carried out in Maryhill, Glasgow; Scottish Index of Multiple Deprivation (1 most deprived); need for intervention
Greig.D.Taylor BSPD Annual Meeting London 2014

3. Background
The British Society of Paediatric Dentistry guideline “National Clinical Guidelines in Paediatric Dentistry: stainless steel preformed crowns for primary molars” highlight the fact that preformed metal crowns outperform direct plastic restorations when restoring multi-surface carious primary molars1.
Reference: 1. SA Kindelan, P Day, R Nichol, N Willmott, SA Fayle, Stainless Steel preformed crowns for primary molars. Int J Paed Dent 2008; 18 (suppl. 1): 20-28
Our body’s guideline suggets that SSC outperform direct plastic restorations when restoring multi-surface caries. This was used as the standard to which I compared my results to.
Greig.D.Taylor BSPD Annual Meeting London 2014

4. Background
Primary carious molars can be treated by conventional caries removal , under LA, and then restored with a SSC. A randomised control study suggested a novel method of placement by cementing the SSC over an unprepared carious tooth.
The results at 23 months report that patients accept this form of treatment, and more favourable outcomes for pulpal health and longevity of restorations in comparison to placement of conventional direct restoration2.
Carried out in Maryhill, Glasgow; Scottish Index of Multiple Deprivation (1 most deprived)
Reference: 2. Innes N, Evans DJP, Stirrups DR. The Hall Technique: a randomised control clinical trial of a novel method of managing carious primary molars in general dental practice. Acceptability of the technique and outcomes at 23 months. BMC Oral Health 2007; 7: 18.
Greig.D.Taylor BSPD Annual Meeting London 2014

5. Aim
To assess the effect on primary caries and the patient experience, when introducing stainless steel crowns as an option of treating carious primary molars in a general dental practice setting.
Greig.D.Taylor BSPD Annual Meeting London 2014

6. Method
All SSC were placed by myself , without the use of local anaesthesia, in accordance with SDCEP guidelines3 over a 6 month period.
An audit tool measured clinical and radiographic outcomes at baseline (Fig 1), 6-months (Fig2) and 12-months (Fig 3).
Consent was obtained from the child’s parent for involvement in this project
Reference: 3. Scottish Dental Clinical Effectiveness Programme. Guidelines: Prevention and Management of Dental Caries in Children. SDCEP, April 2010
Greig.D.Taylor BSPD Annual Meeting London 2014

7. Method Figure 1 – Initial Data Collection
pre-operative assessment of the tooth,
both clinically and radiographically (if applicable);
assessment of whether the patient would accept conventional treatment under local anaesthetic;
if any procedure was required to help the placement of a stainless steel crown;
how safely the stainless steel crown was placed;
if there was any occlusal discrepancy after placement;
a subjective assessment of how the patient coped.
Greig.D.Taylor BSPD Annual Meeting London 2014

8. Method Figure 2 – Six Month data collection
Self reported history from patient;
Clinical evaluation of tooth (if still in place; any evidence of infection, pain, mobiltiy, damage to ssc, replaced)
Radiographic evaluation
Overall success – clinician, parent and patient.
Greig.D.Taylor BSPD Annual Meeting London 2014

9. Method Figure 3 – Twelve Month data collection
Greig.D.Taylor BSPD Annual Meeting London 2014

10. Results Initial Placement N = 34 crowns placed
Total = 17 patients (9males:8females)
Mean: 8.1years
Carried out in Maryhill, Glasgow; Scottish Index of Multiple Deprivation (1 most deprived)
Greig.D.Taylor BSPD Annual Meeting London 2014

11. Results Initial Placement LLE most common; URD least common
Greig.D.Taylor BSPD Annual Meeting London 2014

12. Results Pre-Treatment Assessment
Prior to placement, a subjective assessment suggested that 44.1% of these patients would not tolerate local anaesthesia or use of the high speed.
A discussion with the patient/parent revealed that 100% of the patient reported no symptoms of a reversible or irreversible pulpitis.
LLE most common; URD least common
Greig.D.Taylor BSPD Annual Meeting London 2014

13. Results Pre-Treatment Assessment
Clinical examination showed that 35% showed evidence of marginal breakdown.
LLE most common; URD least common
Greig.D.Taylor BSPD Annual Meeting London 2014

14. Results Pre-Treatment Assessment
A pre-operative bitewing radiograph was undertaken in 79% of the cases.
Of these radiographs it was noted that the extent of caries was “less than half way” into dentine in 56% of cases.
4 patients were not able to tolerate the digital sensor
Greig.D.Taylor BSPD Annual Meeting London 2014

15. Results Placement of Stainless Steel Crown
Prior to placement of the SSC, 9 out of 34 crowns had two separators placed both mesial and distal to the tooth, for a period of 7 days.
Of these 18 separators placed, 16 were still in situ at the time of SSC placement.
88% of cases had sufficient space prior to placement.
The cases which did not achieve space (slipped out of contact point? broken?) – new seperators were placed and at a follow up, sufficient space had now been achieved.
Greig.D.Taylor BSPD Annual Meeting London 2014

16. Results Placement of Stainless Steel Crown
A combination of safety modalities were utilised in 100% of crowns placed.
Due to the nature of the SSC, safety is of extreme importance and it was noted that 100% of the crowns placed were done so using a combination of the three safety modalities mentioned: child sat upright; gauze placed between tooth; SSC secured by tape. No SSC was placed using all three modalities.
Greig.D.Taylor BSPD Annual Meeting London 2014

17. Results Placement of Stainless Steel Crown
100% of SSC were fitted successfully and clinically covered the caries.
3 out of the 34 SSC showed signs of less than ideal interproximal fit. Review 1 week later showed improved and satisfactory clinical fit.
During placement, 3 crowns had not fitted interproximally but 1 week review showed they had intergrated into the correct clinical position.
Greig.D.Taylor BSPD Annual Meeting London 2014

18. Results Placement of Stainless Steel Crown
Greig.D.Taylor BSPD Annual Meeting London 2014

19. Results Placement of Stainless Steel Crown
91% of patients (17 patients) showed none or very mild signs of discomfort during placement of SSC. No patient showed signs of signifcant and unacceptable signs of discomfort.
Greig.D.Taylor BSPD Annual Meeting London 2014

20. Results 6 Month Assessment
All 17 patients were reviewed, and 33 out of the 34 SSC were still present.
1 tooth had been extracted following a trauma which involved losing multiple deciduous teeth
Greig.D.Taylor BSPD Annual Meeting London 2014

21. Results 6 Month Assessment
In 10 patients reported eating difficulty post placement, but this settled down within 24hours. 1 child required analgesia for jaw pain, but settled after a few days
Greig.D.Taylor BSPD Annual Meeting London 2014

22. Results 6 Month Assessment - Clinical
6 of the stainless steel crowns placed had teeth erupting next to them.
One SSC was replaced as it fell out 6 weeks post placement.
The one case where the SSC had worn through/distorted clinically did not require to be repaired, as the margins were clinically sound and no carious lesions were noted.
Greig.D.Taylor BSPD Annual Meeting London 2014

23. Results 6 Month Assessment - Radiographical
Only 30 stainless steel crowns could be assessed as issues with digital sensor tolerance was noted in a few cases.
A few cases should early/moderate signs of physiological root resorption but minimal clinical mobility;
One case showed signs of secondary caries around the margin…this was removed and replaced.
Greig.D.Taylor BSPD Annual Meeting London 2014

24. Results 6 Month Assessment
I felt that 94% (n=32) of the SSC were successful.
97% (n=33) of parents felt the SSC was a success.
100% (n=34) of patients felt the SSC was a success.
I felt two cases were not a success (the one that fell off 6 weeks into the project and the one with secondary caries)
The one case where the parent felt that the SSC had been unsuccessful was where there was secondary caries noted around the margin of the tooth. In this case, the SSC was removed and replaced as that particular parent had experience of other children having SSC placed, and knew how effective they were.
Greig.D.Taylor BSPD Annual Meeting London 2014

25. Results 12 Month Assessment
All patients were reviewed at this stage and 24 out of the 34 SSC and teeth were still present.
9 teeth naturally exfoliated during this 6 month period.
Greig.D.Taylor BSPD Annual Meeting London 2014

26. Results 12 Month Assessment
3 children reported eating difficulty but in all cases, this was due to the mobility caused by the exfoliation process
Greig.D.Taylor BSPD Annual Meeting London 2014

27. Results 12 Month Assessment - Clinical
These results were based on the 24 crowns left in situ at the 12 month assessment visit.
Of the 5 surfaces which were worn through, only 1 required to be repaired and this was done using a Resin-Modified Glass Ionomer (RMGI) restoration.
Greig.D.Taylor BSPD Annual Meeting London 2014

28. Results 12 Month Assessment - Radiographical
Only 22 stainless steel crowns assessed as one child refused radiographic involvement.
A significant number of the SSC showed signs of physiological root resorption, although in most cases it was the early stages as mobility hadn’t set in clinically. One case showed signs of secondary caries around the margin; coincidentally, this tooth had advanced signs of resorption and therefore wasn’t replaced.
Greig.D.Taylor BSPD Annual Meeting London 2014

29. Results 12 Month Assessment
I felt that 97% (n=32) of the SSC were successful.
100% (n=33) of parents felt the SSC was a success.
100% (n=33) of patients felt the SSC was a success.
I was not happy with the secondary caries, however this was not replaced as the tooth showed signs that it would exfoliate in the near future.
All the patients and parents were happy with the SSC and felt they were successful.
Greig.D.Taylor BSPD Annual Meeting London 2014

30. Discussion
The results suggests that SSC are an effective way in treating and restoring the carious primary molars in a safe and timely manner.
These results uphold the national guideline document1 which promotes the use of SSC on the carious primary molar. This guideline and a Cochrane Review4 though suggest there is little evidence to support this practice but do conclude they outperform direct plastic restorations1.
Reference: 4. Inness NPT, Ricketts D, Evans DJP. Preformed metal crowns for decayed primary molar teeth. Cochrane Database of Systematic Reviews 2007
Greig.D.Taylor BSPD Annual Meeting London 2014

31. Discussion
The majority of patients accepted the placement of a SSC with minimal or no discomfort noted.
Bell et al5 concluded that 91.9% (n=57) children reported a positive or neutral response to having the crown put on, irrespective of the technique used.
Reference: 5. SJ Bell, AG Morgan, Z Marshman, HD Rodd. Child and parental acceptance of preformed metal crowns. European Archives of Paediatric Dentistry. 11(Issue 5) 2010.
Greig.D.Taylor BSPD Annual Meeting London 2014

32. Discussion
A handful of patients reported difficulty in eating a few days post placement.
Anecdotally, this may be due to an initial propped open occlusal relationship or indeed tightness around the gingivae
Greig.D.Taylor BSPD Annual Meeting London 2014

33. Discussion
Clinical and radiographic examination at a 6 and 12 month interval prove that SSC are an effective way to restore the carious molar1,2,5,6.
However, there can be certain recognised drawbacks with failure of cementation, occlusal wear and recurrent caries1,2,6 noted in this project – all of which were managed without sacrificing the tooth.
Reference: 6. NPT Innes, DR Stirrups, DJP Evans, N Hall, M Leggate.
A novel tecnhique using preformed metal crowns for managing carious primary molars in general practice – A retrospective analysis. British Dental Journal ; 200:
Greig.D.Taylor BSPD Annual Meeting London 2014

34. Discussion
Every patient felt the placement of a stainless steel crown was a success. However, one parent in this study felt the placement of a SSC was not a success due to secondary caries forming and the crown having to be replaced.
Bell et al5 highlighted that 96.8%(n=60) of parents felt the stainless steel crown did a good job of protecting their child’s tooth and this appears to correlate with our results.
Greig.D.Taylor BSPD Annual Meeting London 2014

35. Discussion Nine teeth exfoliated naturally during the project.
Although this project only ran for 12 months, it does show promising signs that SSC are effective in treating caries in the primary dentition in addition to allowing the transition of the patient into the adult dentition with minimal pain or sepsis.
Greig.D.Taylor BSPD Annual Meeting London 2014

36. Implementation of Findings
I disseminated the results at the monthly practice meeting.
I then ran a 30 minute presentation/demonstration session for all the staff within the practice prior to altering the practice protocol.
Greig.D.Taylor BSPD Annual Meeting London 2014

37. Conclusion
SSC are an effective and successful way to treat carious primary molars in general dental practice setting.
Practice protocol has now changed and SSC are the primary treatment modality for non-infected carious primary molars.
Greig.D.Taylor BSPD Annual Meeting London 2014